Healthcare Provider Details

I. General information

NPI: 1265381800
Provider Name (Legal Business Name): JALISSA C KELLY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JALISSA C LUDLEY

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MAIN ST FL 18
COLUMBIA SC
29201-2435
US

IV. Provider business mailing address

1901 MAIN ST FL 18
COLUMBIA SC
29201-2435
US

V. Phone/Fax

Practice location:
  • Phone: 839-207-0558
  • Fax: 839-207-0558
Mailing address:
  • Phone: 839-207-0558
  • Fax: 839-207-0558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number31456
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: